Context Intimate partner violence is prevalent and is associated with significant
impairment, yet it remains unclear which interventions, if any, reduce rates
of abuse and reabuse.

Objective To systematically review, from the perspective of primary health care,
the available evidence on interventions aimed at preventing abuse or reabuse
of women.

Data Sources MEDLINE, PsycINFO, CINAHL, HealthStar, and Sociological Abstracts were
searched from the database start dates to March 2001 using database-specific
key words such as domestic violence, spouse abuse, partner abuse, shelters, and battered women. References of
key articles were hand searched. The search was updated in December 2002.

Study Selection Both authors reviewed all titles and abstracts using established inclusion/exclusion
criteria. Twenty-two articles met the inclusion criteria for critical appraisal.

Data Extraction Following the evidence-based methods of the Canadian Task Force on Preventive
Health Care, both authors independently reviewed the 22 included studies using
an established hierarchy of study designs and criteria for rating internal
validity. Quality ratings of individual studies—good, fair, or poor—were
determined based on a set of operational parameters specific to each design
category developed with the US Preventive Services Task Force.

Data Synthesis Screening instruments exist that can identify women who are experiencing
intimate partner violence. No study has examined, in a comparative design,
the effectiveness of screening when the end point is improved outcomes for
women (as opposed to identification of abuse). No high-quality evidence exists
to evaluate the effectiveness of shelter stays to reduce violence. Among women
who have spent at least 1 night in a shelter, there is fair evidence that
those who received a specific program of advocacy and counseling services
reported a decreased rate of reabuse and an improved quality of life. The
benefits of several other intervention strategies in treating both women and
men are unclear, primarily because of a lack of suitably designed research
measuring appropriate outcomes. In most cases, the potential harms of interventions
are not assessed within the studies reviewed.

Conclusions Much has been learned in recent years about the epidemiology of violence
against women, yet information about evidence-based approaches in the primary
care setting for preventing intimate partner violence is seriously lacking.
The evaluation of interventions to improve the health and well-being of abused
women remains a key research priority.

Since the 1970s, intimate partner violence increasingly has been recognized
as associated with significant morbidity and mortality, particularly among
women.1 While some surveys suggest that similar
proportions of men and women report intimate partner violence (IPV), abused
women experience more physical and emotional impairment than men.2-4 It is not surprising,
therefore, that the great majority of interventions aimed at prevention and
treatment of IPV focus on violence by men against women. Although violence
against men by women and between same-sex partners are important issues, presently
there are too few original research articles with this focus to warrant a
systematic review of these topics.

Violence surveys generally place lifetime prevalence of IPV against
women at between 25% and 30% and annual prevalence at between approximately
2% and 12%.2,5 A recent Canadian
population-based survey found 5-year rates of 8%,3 a
decrease from 12% found in an earlier survey.6 In
Canada, 1-year rates in 1999 were reported at 3%.7 The
variability in these estimates has been attributed to a variety of factors,
such as the definition of abuse used in the survey
(ie, whether emotional and verbal abuse, stalking, and rape are considered);
whether the samples are drawn from community or health care settings; and
whether the respondents are asked to restrict their responses to abuse in
the current relationship.2,6,8

Similarly, prevalence estimates for abuse during pregnancy have significant
variability.9 In their review of pregnant women
from the United States and other developed countries, Gazmararian and colleagues10 found rates of abuse ranging from 0.9% to 20.1%,
with the majority in the range of 3.9% to 8.3%, which is consistent with US
state-wide surveys.11,12 There
is a relationship between abuse before, during, and after pregnancy, with
abuse during an earlier period in the relationship strongly predicting abuse
during a later period.11,13

Women who experience IPV are at increased risk of injury and death,
as well as a range of physical, emotional, and social problems.14 Physical
health consequences include a 50% to 70% increase in gynecological, central
nervous system, and stress-related problems.8,15 Impairment
in mental and emotional health is associated with exposure to IPV, including
depression, anxiety, suicidality, posttraumatic stress disorder, mood and
eating disorders, substance dependence, antisocial personality disorders,
and nonaffective psychosis.16-19

Abuse during pregnancy is associated with impairment in both the mother
and child. For the mother, the outcomes described above are all relevant,
as well as the additional psychological and physical implications of experiencing
abuse while pregnant. For the child, abuse can cause direct harm, such as
preterm birth or injury caused by a blow to the mother's abdomen, or indirect
harm caused by psychological distress, and/or a woman's reluctance or inability
to obtain prenatal care.20,21 A
recent meta-analysis and systematic review found that women abused during
pregnancy are significantly more likely to give birth to low-birth-weight
infants.22

Given the recent emphasis on development of primary care screening approaches
for IPV, this article systematically reviews the available evidence for strategies
applicable in the primary care setting to identify and treat women who experience
IPV. In a companion article, Rhodes and Levinson23 discuss
the clinical applications of the evidence in the context of options available
to primary care clinicians.

Methods

Data Sources

MEDLINE, PsycINFO, CINAHL, HealthStar, and Sociological Abstracts were
searched from the respective database start dates to March 2001 using appropriate
database-specific keywords such as domestic violence, spouse abuse, sexual abuse, partner abuse, shelters, and battered women, among others. The reference lists of key
articles were hand searched. Both primary authors reviewed all titles and
abstracts according to the study selection criteria (see "Study Selection"
below) to arrive at a final pool of articles for review. Also included were
relevant articles from after the search end date and those articles identified
by external reviewers.

A total of 2185 citations were retrieved during the first search. Twenty-two
citations were identified via hand searching and a focused search update.
One reviewer (C.N.W.) reviewed all titles and abstracts and created keep and
reject databases in Reference Manager 9.0 (ISI Research Soft Inc, Berkeley,
Calif). The second reviewer (H.L.M.) examined both databases and made necessary
adjustments according to the study selection criteria. A total of 237 articles
appeared from titles and abstracts to match the selection criteria; these
articles were then retrieved in full length for further review. The final
pool of articles was 97, 22 of which described interventions meeting the criteria
for critical appraisal. An additional 18 articles, suggested by external expert
reviewers and/or those published between the search end date and an updated
focused search in December 2002, were added, none of which met the selection
criteria for critical appraisal.

Both authors independently reviewed each study using the evidence-based
methods of the Canadian Task Force on Preventive Health Care
(Box).24 Quality ratings of individual studies—good,
fair, and poor—were determined based on a set of operational parameters
specific to each design category (eg, systematic review, case-control studies,
randomized controlled trials [RCTs], and cohort studies) developed with the
US Preventive Services Task Force.25

Levels of EvidenceA. Research design rating
I: Evidence from at least 1 randomized controlled trial.
II-1: Evidence from controlled trial(s) without randomization.
II-2: Evidence from cohort or case-control analytic studies, preferably
from more than 1 center or research group.
II-3: Evidence from comparisons between times or places with or without
the intervention; dramatic results from uncontrolled studies could be included
here.
III: Opinions of respected authorities, based on clinical experience;
descriptive studies or reports of expert committees.

B. Quality (internal validity) rating†
Good: A study that meets all design-specific criteria well.
Fair: A study that does not meet (or it is not clear that it meets)
at least 1 design-specific criterion but has no known "fatal flaw."
Poor: A study that has at least 1 design-specific "fatal flaw," or an
accumulation of lesser flaws to the extent that the results of the study are
not deemed able to inform conclusions.

*The Canadian Task Force methodology is described in Woolf
et al24 or available from the Canadian Task Force Web site: http://www.ctfphc.org, under History and Methods.
†General design-specific criteria by study type are outlined
in Harris et al.25

Study Selection

For this review, IPV was defined as physical
and psychological abuse of women by their male partners, including sexual
abuse and abuse during pregnancy. The systematic review focused on the effectiveness
of interventions to prevent IPV, including all comparative studies evaluating
interventions to which a primary care clinician could refer a patient. These
studies included interventions for women, batterers, and/or couples. The type
of comparison group could be a no intervention control, a usual care control,
or a group receiving an alternate intervention for study purposes.

In the case of physical, sexual, and emotional violence, the primary
health outcomes (ie, changes in disease morbidity or mortality) are those
related to physical and psychological morbidity of abuse; however, these data
often are not available. Thus, self-reported incidence of abuse is often used
as the primary outcome in these studies; however, there is evidence that women
underreport abuse.3

Furthermore, debate exists regarding whether incidence of reabuse is
the appropriate measure for evaluating treatment interventions. For example,
many authors argue that reabuse is an inappropriate measure because women
have no control over whether they are abused again, and they are often forced
to return to an abusive relationship for economic or other reasons. Some authors
claim that the significant outcomes should be determined by the women themselves.26,27 Other types of outcomes suggested
in the literature include the impact of clinically based interventions (eg,
screening, counseling) on the patient-physician interaction and subsequent
physician action if women are identified as abused,28 whether
women revisit emergency departments (EDs),29 and
whether women's mental health improves,30 among
others. However, these were not considered primary outcomes for the present
review, largely because of a lack of analytic studies.

Thus some studies, especially those describing interventions for women,
do not provide outcomes for abuse per se, and the main outcome measures are
those such as the amount of social support the women have access to, their
use of safety behaviors or safety planning, or their use of community resources.
While the link between these types of outcomes and subsequent abuse has not
been empirically established, studies that meet other inclusion criteria and
report only these types of outcomes are included in the analysis, with a caveat
that they can inform effectiveness of interventions only vis a vis these outcomes.
Potential harms of interventions also are reviewed. In their companion article,
Rhodes and Levinson23 elaborate on the issue
of relevant clinical outcomes to consider in primary care decision making.

Results

Interventions to Prevent Abuse: Systematic Review

From the primary care perspective, there are 2 main intervention options
to detect and to prevent violence against women. Primary care clinicians can
screen women to determine if they are being abused or are at risk of abuse,
and they can refer abused women or their partners to various intervention
programs.

A number of screening tools exist, many of which have shown reasonable
accuracy in detecting abuse,31-41 including
tools designed for primary care settings,42,43 to
screen pregnant women,44-47 and
even a tool designed to screen men.48 However,
no study to date has examined, in a comparative design, the effectiveness
of screening where the end point was improved outcomes for women (as opposed
to identification of abuse status). Therefore, this systematic review focuses
on the effectiveness of treatment interventions for women identified as at
risk of or experiencing IPV. From the perspective of the primary care clinician,
this effectiveness of screening generally means a referral to either a safe
place, such as a women's shelter, to counseling, or to other community-based
resources.

Another set of intervention options is referral of men to batterer treatment
programs. Compared with interventions for women, more empirical data exist
evaluating the effectiveness of different treatments for men. The link between
detecting IPV in men and then treating the men is not clear, especially for
the primary care clinician. However, given the potential for the reduction
in IPV through treatment of perpetrators,49-51 it
is important to understand the effectiveness of these approaches.

A few studies have examined the effectiveness of information and education
interventions targeted at young people as primary prevention strategies for
later domestic violence.52-54 Also,
some authors have proposed that societal-level interventions, such as policing
and legislative policies, can affect the incidence of violence against women.55-59 These
latter interventions are considered to be outside the scope of the primary
care setting, but a brief section outlining the key issues surrounding these
types of policies is provided.

Interventions for Women

No interventions for use in the primary care setting, to our knowledge,
have been evaluated in studies meeting the inclusion criteria for this systematic
review. Eleven studies that met the inclusion criteria were classified as
interventions to which primary care clinicians could refer abused women. These
11 articles described 4 interventions, with advocacy counseling following
at least 1 night's stay in a shelter as the subject of 6 articles.60-65 The
other interventions included an assessment of the effectiveness of staying
at a shelter,66 a program of personal and vocational
counseling for abused women,67 and prenatal
counseling designed to reduce further abuse.68-70Table 1a
(truncated version;
online eTable 1
is the full version of the table) shows studies with a quality rating of fair. Strict adherence to the a priori
criteria established for this review resulted in no studies receiving a quality
rating of good. Often, a main limitation was the use of self-report data as
the primary outcome (incidence of violence) using a measure(s) that had not
undergone adequate testing of its validity. Thus the highest level of evidence
available would have been outcomes, including self-report data, that had been
validated, for example, by medical or police records.

No studies meeting the criteria for a quality rating of good or fair
exist that test the effectiveness of shelters for battered women. Using a
cohort design, Berk et al66 interviewed battered
women (identified either by their referral to a shelter or to the county prosecutor),
comparing those women who had elected to enter a shelter during the interval
between interviews (mean of 54 days) with those who had not. Of 155 women,
37% (n = 57) reported 1 shelter stay between interviews. Most of the sample
(81%, n = 125), regardless of shelter status, reported no new violence in
the time between interviews
(for details of this study see the online
eTable 1). Of the 30 women (19%) experiencing
violence, 22 (14%) reported a single incident, and 8 (5%) reported multiple
incidents. Rates of reported violence did not differ between those who stayed
at a shelter and those who did not. This study had several methodological
weaknesses, including selection bias. The relatively short interval between
interviews made it difficult to interpret whether the lack of reported violence
in the majority of the sample was due to the intervention, the women's participation
in the study, or the relatively short time between intervals.

Advocacy counseling following shelter stay was evaluated using an RCT
design, in a pilot study,60,61 and
in a larger trial.62-65 The
study reported by Sullivan and Bybee65 included
the largest sample and reported the longest follow-up period (2 years) (Table 1). Overall, this study was assessed
as having fair internal validity, mainly because of reliance on self-report
measures for all of the outcomes. Women who had spent at least 1 night in
a shelter were randomly assigned either to receive advocacy services 4 to
6 hours a week for 10 weeks following leaving the shelter or to have no contact
other than for interviews. The focus of the intervention was on assisting
women with devising safety plans (if needed) and accessing community resources,
such as housing, employment, and social support. Of the 284 initial study
participants, 278 women remained in the trial, and complete longitudinal data
were available for 242 of them. Women in the intervention group reported less
reabuse at the 2 year follow-up compared with those in the control group (76%
and 89%, respectively). In addition, physical violence decreased for the intervention
group across time and there was a group by time interaction. Quality of life
also was better for women in the intervention group and improved across time.
No differences were observed in reports of psychological abuse or depression.
There was an increase in self-reported intermediate outcomes for the intervention
group, including social support and effectiveness in obtaining resources.
The secondary outcome did show improvement at earlier points in the follow-up—ability
to obtain resources was improved immediately postintervention62 and
at 6 months follow-up63; satisfaction with
social support was evident at the immediate postintervention period (at 10
weeks) as well as at 2 years.65

A personal and vocational counseling program for abused women who had
remained in a women's protective service for at least 2 weeks was evaluated
(for details of studies not shown in
Table 1,
see the online eTable 1).67 However, this study had a small initial sample
(N = 50) and high drop-out rates. Although there was some improvement in measures
such as self-esteem, the limits in the design and analysis did not allow for
conclusions to be drawn from this study.

Prenatal counseling for pregnant women with a history of abuse was evaluated
using 1 or more comparison groups.68-70 McFarlane
et al's 1997 study68 focused on the relationship
between resource use and reports of abuse, rather than on the effectiveness
of the intervention. In a cohort study, 3 sessions of individual counseling
by a nurse trained for abuse prevention were provided to 132 women.68,70 A comparison group of 67 postpartum
women were given an information card containing telephone numbers of local
agencies that assist with domestic violence.68,70 While
women who received the counseling intervention reported less violence, flaws
in study design, such as difference in parity status between the 2 groups,
precluded determining the effectiveness of the intervention.68,70 In
a recent quasi-randomized trial by McFarlane and colleagues,69 3
levels of intervention—brief (information card), counseling (professional),
and outreach (professional plus "mentor mother")—were compared in a
sample of predominantly Hispanic women who were pregnant and had experienced
physical abuse. Although severity of abuse decreased significantly across
all intervention groups, there were no statistically significant differences
among the groups at 18 months. Furthermore, the methodological shortcomings
of the trial, including a flawed randomization procedure, have limited the
conclusions that can be drawn from this study.

Interventions for Batterers and/or Couples

Ten studies49,51,72-79 and
1 systematic review50 of batterer and/or couple
programs are summarized in
Table 2a (truncated
version showing only those studies with quality ratings of good and fair;
online eTable 2 is the full version
of the table). Some of these intervention programs are aimed exclusively at
men while others include their partners. Within individual studies, more than
1 treatment approach often was evaluated. More than half of the studies compared
treatments without a control group; only 2 studies51,72 used
an RCT design. The systematic review50 included
2 RCTs, one of which overlapped with the individual studies.49

The systematic review was given a quality rating of fair.50 While
the methodological quality of the individual studies was assessed in detail
within the review, it was unclear whether 2 authors independently assessed
the studies, and search strategies were not described. Of the 10 individual
studies, only 1 was given a quality rating of good.51 While
several of the studies rated poor or fair reported some evidence of effectiveness
for interventions aimed at batterers and/or couples,49,74 the
study of good quality concluded that 3 types of interventions were not effective
in reducing subsequent violence against women.51

This RCT study51 of good quality, the
San Diego Navy Experiment, tested 12-month interventions, which included group
sessions for men, group sessions with men and their female partners (conjoint),
and rigorous monitoring with monthly individual counseling sessions, compared
with a control group. Men assigned to the control group received no Family
Advocacy Center treatment, although their partners received stabilization
and safety planning assistance like all partners in the treatment groups.
This study involved a large sample of couples (N = 861), had a low attrition
rate, and measures included both self-reports of abused women and perpetrators
as well as police arrest records. Since the sample consisted entirely of US
Navy couples, it is not clear how these results can be generalized to other
populations. As Dunford emphasized, however, this military setting provided
certain advantages in that all men in the intervention groups were required
to attend treatment. Also, Dunford highlights the fact that many of the batterer
treatment programs described in the literature that reported success did not
use an experimental research design. In the trial by Dunford, the low recidivism
rate among those men who received 1 of the 3 treatments did not differ from
the rate among control subjects. It is possible that employment in a military
setting acts as a deterrent among men who commit violence against their wives.
This trial was not able to control for this variable, since all participants
were US Navy couples where the husband was on active duty. It is important
to note recidivism rates were low in all treatment groups (range, 3% to 6%)
and the control group (4%) compared with the rates reported in other studies.

Other Interventions

The studies in the following sections evaluate interventions in settings
outside the scope of primary care and did not meet the inclusion criteria
for critical appraisal. These studies are included to provide a complete picture
of the research conducted to date to prevent IPV.

Emergency Department Interventions. Approximately 37% of women presenting in EDs report having experienced
emotional or physical abuse at some point during their lives; 2.2% report
acute physical trauma resulting from partner abuse, and 14.4% report having
been abused in the past year.80 In response
to these significant proportions and also to the accreditation standards implemented
in 1992,1 interventions designed for ED settings
have been designed and evaluated. Fanslow et al81,82 developed
and examined a protocol of care for individuals abused by their partner and
provided 1-year follow-up data. This was a comparative study of the only 2
EDs in Auckland, New Zealand. The protocol was based on the principles of
care outlined by the American Medical Association,83 including
providing staff training on recognizing signs and symptoms indicative of domestic
violence, asking appropriate screening/case-finding questions, assessing immediate
risk and providing appropriate intervention (including depression assessment,
counseling about police and legal options, and safety planning, in addition
to treatment of physical injuries), and referral to community and social services.
To determine the presence or absence of assault and how it was treated, baseline
data were acquired in both hospital EDs via random chart audit of women older
than 15 years. Following this, medical and reception staff in the intervention
ED were trained to implement the protocol.

Results immediately postintervention (experimental group, n = 2276;
comparison group, n = 1768) indicated that more cases of domestic violence
were rated as confirmed (rather than suspected) following the implementation
of the intervention protocol at the ED experimental site, and a trend toward
improved documentation of abuse was observed.81 These
findings were coupled with a significant increase in use of treatment interventions
in the experimental ED, particularly in safety assessment and planning, counseling
regarding use of police and law enforcement services, and referral to other
treatment services. However, these positive changes were not maintained at
the 1-year follow-up.82 The authors attributed
the lack of sustainability of use of intervention programs to a failure in
ongoing maintenance training of the ED staff, rather than to problems with
the intervention protocol itself, thus limiting the generalizability of this
study. Of note, the prevalence of domestic violence–related presentation
to the ED in this New Zealand sample was low compared with samples from North
American populations (2.6% of all presentations and 7% of trauma presentations
to the ED were because of partner abuse); and the intervention protocol advocated
a case-finding approach based on presenting symptoms, rather than a routine
screening approach.81,82

Similarly, there is some evidence that system-based training of ED professionals
can improve the identification of and response to violence against women84; however, more research is required to determine
if this kind of approach will improve identification of abused women (especially
those presenting without trauma, who are a significant proportion).85 Again, the subsequent key link between identification
of abuse and treatment or outcomes requires investigation and substantiation.

Social Interventions. In the sole study using a comparison group and measure of appropriate
outcomes, Davis and Taylor86 conducted a unique
RCT in New York City testing 2 types of public intervention programs addressing
both primary and secondary prevention of violence. Their primary prevention
initiative randomly assigned 64 housing projects (approximately 93 000
individuals) to receive or not to receive a public education campaign against
violence, consisting of tenant meetings, leaflets, and posters. Their secondary
prevention intervention randomly assigned households of 436 individuals (380
women [87%] and 56 men [13%]), who experienced family violence (as identified
by a police-reported complaint) and who were drawn from public housing households
in 3 New York City precincts to receive or not to receive a 10- to 30-minute
home follow-up visit from a police officer and social worker. For both interventions,
outcome measures included interviews with individuals abused regarding subsequent
violence (as measured using the Conflict Tactics Scales),31 reports
to police, abused women's knowledge and use of intervention services, and
official police reports of violence. Measures for both interventions were
collected during a 6-month follow-up. Results indicated that for abuse outcomes,
neither public education nor home visits reduced the frequency of new violence
or severity of violence reported by abused individuals. In the secondary prevention
intervention, abused individuals who received public education and those who
received home visits called the police more frequently compared with their
respective controls. Neither of the interventions affected service-awareness
or service-use scores of individuals abused. The study was generally well-conducted,
although some misassignment of the home-visit intervention (16.6% of cases)
was reported, and there was a lack of blinding. (The analysis did not show
any pattern to the misassigned cases). Loss to follow-up was moderate (28%).

In other efforts aimed at primary prevention of partner abuse, some
studies have attempted to evaluate the effect of educational campaigns directed
at young people.52-54 A
major limitation of these studies is that the main outcome is change in knowledge
and attitudes either immediately postintervention or after a brief follow-up.
No such study reviewed has attempted to follow the subjects for an extended
period to determine the impact of education on later incidence of IPV.52-54 Use of rigorous designs
is required to determine if educational approaches reduce the rates of IPV.

Legal and Policy Interventions. An important and well-publicized series of research studies was conducted
in the 1980s to determine the effectiveness of various police responses to
domestic violence. The original study, the Minneapolis Domestic Violence Experiment,
had police officers respond to calls of misdemeanour domestic violence according
to 1 of 3 randomly selected protocols: arrest the perpetrator, separate the
couple, or provide advice.55 The study found
that violence recidivism rates 6 months later were significantly lower for
those arrested than for the other groups.

These results had a significant effect on public policy in the United
States, with arrest becoming a main strategy for dealing with misdemeanor
domestic violence and the perception of domestic violence changing from a
personal family problem, to a crime.1 However,
a series of 6 replication studies, the Spouse Abuse Replication Program, which
were funded to confirm the original results, found variable levels of the
effectiveness of arrest.56 In some sites, there
was an escalation of subsequent violence among the arrested men, while other
sites showed the predicted deterrent effect.56

A key finding arising from these studies was the importance of interaction
effects between individual characteristics and arrest. For example, arrest
has a much stronger deterrent effect on employed men (ie, those who have more
to lose) than unemployed men.57 The implications
of these types of findings have not been studied.1 The
arrest policies arising from this research led to many subsequent studies
on the effectiveness of batterer treatment programs, since this type of treatment
is often mandated as a probation requirement.

A recent retrospective cohort study evaluating the association between
civil protection orders and subsequent police-reported violence found that
permanent (12-month), but not temporary (2-week) protective orders, as compared
with no orders, were associated with a significant (80%) decrease in reported
incidence of physical violence in the year following the initial incident.58 Temporary, but not permanent, orders were associated
with a significant increase in psychological abuse, but no change in physical
abuse.

In a recent pilot study evaluating the role of legal advocates for women
entering the court system to obtain civil protection orders, Bell and Goodman59 used a quasi-randomized design to compare women receiving
advocacy services (including legal representation and support, as well as
referral to community agencies, information about abuse, and other forms of
social and instrumental support) with those not receiving these services.
Results indicated significantly less psychological and physical reabuse in
the intervention group as compared with the comparison group. While this study
was small and had some methodological weaknesses (nonstandard randomization
procedure, high loss to follow-up in the comparison group, and restrictions
on eligibility of women in the intervention group), its positive results are
promising and additional research would seem warranted.

Few comparative studies have examined the influence of other legal or
policy interventions on domestic violence outcomes.1

Potential Harms of Interventions. No studies to date have evaluated either the benefits or harms associated
with the use of screening tools, including the potential harms from failing
to identify women who have experienced abuse. Similarly, none of the interventions
developed to prevent or to reduce violence against women used measures to
determine possible harms associated with the intervention. Several of the
studies compared different treatment groups without comparison to a no treatment
or usual care group, so the likelihood of identifying any harms associated
with the interventions was reduced. The results of the study by Berk et al66 suggest that the use of shelters might increase the
risk of further abuse for some women. This possible risk of reprisal violence,
while not yet measured directly, is a potential concern,87 and
indeed it was the main patient-related barrier to screening cited (by 82%
of respondents) in a study that surveyed primary care physicians about their
screening and intervention practices for IPV.88 Clinicians
should consider this risk, as it underscores the need to conduct visits that
include discussion of these issues in a private setting, with adequate safety
and confidentiality measures taken in any referral process.

Summary of Key Evidence

Screening instruments are available to identify women who have been
abused, but no studies to date have evaluated the effectiveness of screening
to reduce violence or to improve women's health. In addition, data about the
potential harms associated with screening are lacking.

No current evidence of suitable quality exists in the literature reviewed
to evaluate the effectiveness of shelter stay as a means of decreasing the
incidence of violence. Among women who had spent at least 1 night in a shelter,
there was fair evidence that those who received a specific program of advocacy
counseling services reported a decreased rate of reabuse and an improved quality
of life during the subsequent 2 years.65 With
regard to other types of interventions for women, limitations in the available
studies precluded drawing any conclusions about program effectiveness.67-70

Programs that target male batterers alone or with their partners represent
the largest group of interventions. Of 10 studies and 1 review, only the trial
by Dunford51 was considered of good quality.
This RCT showed that 3 intervention programs for batterers and/or their female
partners did not reduce domestic violence in the intervention groups compared
with the control group, which did not receive any treatment. Despite the excellent
internal validity of this trial, it is unclear to what extent these findings
are applicable to the general population since the sample consisted entirely
of US Navy couples.

One study found that a protocol for treatment of abused women in the
ED showed some initial positive changes (such as referral to other intervention
services), but these were not sustained at 1 year.81,82 A
study of 2 community-based interventions (public education and police and
social worker home visits) showed that neither intervention affected service-awareness
or service-use scores of individuals who experienced abuse.86 A
second education intervention that targeted youth in schools focused on change
in knowledge and attitude and did not include a control group.52 A
series of US studies evaluating the effectiveness of arrest as a deterrent
for recurrent domestic violence showed mixed results. Although the original
study55 suggested that arrest was effective
in reducing subsequent domestic violence compared with separating the couple
or providing advice, 6 replication studies found variable results including
increases in violence.56 Finally, an initial
study of the use of civil protection orders58 and
an innovative pilot study of legal advocacy and counseling59 showed
promising results that these legal interventions can reduce physical abuse.

Comment

Although much has been learned in recent years about the epidemiology
of violence against women, information about evidence-based approaches in
the primary care setting for preventing IPV is seriously lacking. Our findings
are consistent with those of Ramsay et al,89 whose
recent systematic review concluded that there is a lack of evidence regarding
the effectiveness of interventions for women experiencing abuse and that potential
harms of identifying and treating abused women are not well-evaluated. They
conclude that it is premature to recommend universal screening programs in
health care settings, a finding similar to that of the Canadian Task Force
on Preventive Health Care.90 Specifically,
the effectiveness of routine primary care screening remains unclear, since
screening studies have not evaluated outcomes beyond the ability of the screening
test to identify abused women. Similarly, specific treatment interventions
for women exposed to violence, including women's shelters, have not been adequately
evaluated. The notable exception is the advocacy counseling program following
a stay in a shelter of Sullivan and Bybee.65

It is important to distinguish between asking about abuse during the
diagnostic evaluation of a patient and routine screening for domestic violence
in health care settings. Questions about experiencing IPV should be included
in any medical or psychiatric assessment of a patient with symptoms or signs
that could be associated with such experience, and it is important for clinicians
to be alert to these signs. Some authors have suggested that asking female
patients about experiencing violence during routine history taking may be
justified on the basis of prevalence alone, or the potential value of this
information in caring for the patient, and may influence assessment and treatment
of other health problems.91,92 Furthermore,
failing to detect that a patient is at risk for or has experienced IPV may
lead to unnecessary investigations and interventions.2,15,93 Rhodes
and Levinson,23 in their companion article
to this review, further discuss these issues, their implications for clinical
practice, and the role of existing practice guidelines.

Research Agenda

There is an urgent need for additional research using rigorous designs
to test the effectiveness of IPV interventions on important clinical outcomes.
While research in this area is challenging, a number of questions need to
be answered, both to allow primary health care clinicians to respond appropriately
to IPV and to inform a more proactive approach to prevention at the level
of public policy. Chief among these questions is whether screening in health
care settings, coupled with appropriate, effective treatments, reduces physical
injury and psychological abuse. Research is also required to determine whether
batterer interventions are effective with men not mandated to treatment and
not monitored by courts or other authorities.

Ongoing studies funded by the National Center for Injury Prevention
and Control, the Agency for Healthcare Research and Quality, the Centers for
Disease Control and Prevention, and the Canadian Institutes for Health Research,
may answer some of these questions.